Circumcision

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The intact and circumcised human penis, side by side.

The term "circumcision" without a gender qualifier refers specifically to male circumcision. It means "to cut around," and it refers to the excision of the foreskin from the penis. Circumcision is most often performed in healthy males for religious or cultural reasons. The procedure may be performed on consenting adults, but it is most often performed on non-consenting minors, particularly newborn children, which is why the ritual is so controversial. Opponents of circumcision consider the circumcision of non-consenting minors to be unethical and a human rights violation, unless there is concrete medical indication. Proponents of circumcision consider the circumcision of non-consenting minors to be a "religious freedom" and a "parental right."

Contents

Rationale

Reasons for performing circumcision range widely by culture, religion, location, and age.

Cultural

Many cultures perform circumcision as a rite of passage into manhood. This is common in the Middle East and amongst some indigenous African and Southeast Asian peoples.

The United States and Israel are the only industrialized countries in the world to have a high incidence of routine infant male circumcision. The vast majority of infant circumcisions performed in the United States are for non-religious, non-medical reasons. See History of Circumcision.

Religious

The circumcision of newborn boys is seen as a divine commandment in the Jewish faith. Though absent in the Koran, male circumcision is considered a religious requirement in Islam, and it is performed on male children of varying ages. Converts to these faiths may also choose to undergo circumcision, but it is not always required.

Medical Indication

In some cases, circumcision is legitimately indicated; a patient may be suffering recurring infections, and other methods of treatment have failed. In other cases, a patient may be suffering from a severe case of phimosis. Overall, the actual medical necessity for circumcision is extremely rare.

Arguments of Prophylaxia

Though the practice of ritual circumcision of males, both consenting and non-consenting, has existed for millenia, the search for "potential medical benefits" began relatively recently. Initially, circumcision was adopted as a way to stop boys and men from masturbating, where mastubration was seen as the cause for many diseases. As the myth that circumcision prevented masturbation became debunked, advocates of circumcision began the great search to find the "medical benefits" of circumcision.

Male and female circumcision involves the removal and disruption of normal anatomical structures that are primary areas of sexual sensation.[1] In the past, some advocates of mass circumcision have considered the prepuce to be a "mistake of nature,"[2] but this notion has no validity because the prepuce is ubiquitous in primates and because it provides functional advantages.[3]

Circumcision Methods

Circumcision is performed in many ways which vary by culture, the person performing it, and the age of the subject. It may be performed by a specialized ritual circumciser in a non-medical setting, or a medical practitioner at a hospital or clinic. In some cultures, only the protruding end of the foreskin is cut off, and in others, the entire foreskin which covers the glans is removed. Some circumcisers take more skin than others, resulting in a "loose" or "tight" circumcision.

Generally, the foreskin is pulled forward and enough of it is removed to permanently expose the glans of the penis. Sometimes a protective device is used to avoid hurting the glans, and sometimes the circumciser simply performs the procedure freehand. In adults, stitches are used to stop the bleeding and help close the wound. In infants, circumcisers often use a clamp that crushes the foreskin and seals the wound, eliminating the need for stitches.



Complications

Pain

In the past, advocates of circumcision claimed that a newborn child's nerve system was not yet fully developed, and that as a result, the child felt no pain during the circumcision procedure. Research has shown that newborn children do in fact feel pain, and more acutely than adults. This has led American health associations to recommend doctors take measures to reduce the pain of circumcision in infants.

The AAP Circumcision Policy Statement states quite clearly that "There is considerable evidence that newborns who are circumcised without analgesia experience pain and physiologic stress". Furthermore, the pain is quite severe, and requires injections for proper pain management. Sucrose and Acetaminophen "cannot be recommend as the sole method of analgesia". Topical cream is no longer thought sufficient as "the analgesic effect is limited during the phases associated with extensive tissue trauma such as...tightening of the clamp".[4]

The AAFP states quite simply in their position paper, "Newborns experience pain during circumcision".[5] This is not a debatable fact, and yet, it is not widely accepted, even by some doctors. It might be hard for some doctors to accept, as they may have been taught that the infant does not feel pain, and may have performed countless circumcisions with this idea. Usage of anesthesia for infant circumcision is still by no means the rule.

Penile injections of anesthetic are now recommended by all of the major medical institutions. In their Report 10 of the Council on Scientific Affairs, the AMA states "When the decision is made to proceed with circumcision, local anesthesia should be provided for the procedure. Ring block or dorsal penile blocks [injections] are most effective. EMLA cream has limited utility". Alarmingly, "Despite the clear evidence that newborn males generate brisk pain responses during circumcision, a recent survey of residency training programs found that 26% of programs that taught circumcision provided no instruction on the use of local anesthesia". The AMA reports that "Of physicians performing circumcision, 45% use anesthesia, 71% of pediatricians, 56% of family practitioners, and 25% of obstetricians".[6]

The AAP's Heatlhy Children website suggests "Your pediatrician (or your obstetrician) should discuss the forms of analgesia that are available".[7] Be that as it may, few forms of analgesia are recommended. There are basically two types of injections to choose from, and the website does not go into the difference between a 'dorsal nerve block' and a 'ring block' injection.

Given what is known from aforementioned official documents, the AAP website may be more informative and effective if it would say "Make sure your doctor knows of the ineffectiveness of anything short of local anesthesia, and make sure your baby is given an injection. This is your responsibility, because your doctor may or may not be up to date on the latest understandings of infant sensitivity to pain during circumcision." The AAP may be holding back, however, perhaps because this would upset the doctor/parent power relationship, and may cause too much questioning of doctors in general. One may not expect to find this kind of advice on such a website, and yet, anything less than this is a dangerously weak statement.

To control pain, some physicians that circumcise use Tylenol, sugar,[8][9] a topical cream,[10] and/or a local anaesthetic injection called a dorsal penile ring block.[11] Topical anaesthetic only serves to numb the area to lessen the pain of the injection, but studies have shown that a dorsal penile ring block is not always effective in stopping the pain of circumcision.[12][13] During circumcision, somp physicians give children sugar pacifiers to "reduce the perception of pain",[14] but in at least one study, data shows that giving sugar to a child doesn't help to reduce the perception of pain in the child.[15] Post-operative pain and the pain the child must endure during recovery is hardly, if ever, addressed by professionals.

It has been shown that an infant's response to pain can be altered for years as a consequence of circumcision.[16][17]

Sexual effects

Circumcision and frenectomy remove tissues with heightened erogenous sensitivity. Boyle et al. (2002) wrote, "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision."[18] They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

The amputation of the prepuce results in the loss of the majority of fine-touch neuroreceptors found in the penis, leaving only the uninhibited protopathic sensibility of the artificially externalized glans penis. The imbalance caused by not having the input from the now ablated fine-touch receptors may be a leading cause of the changes in sexual behavior noted in circumcised human males.[19]

Histology of the male circumcision scar shows amputation neuromas, Schwann cell proliferation and the bulbous collection of variably sized neurites. Amputation neuromas do not mediate normal sensation and are notorious for generating pain.[20]


Death

A study in 2010 estimated approximately 117 neonatal circumcision-related deaths occur annually in the United States, about one out of every 77 male neonatal deaths, more than suffocation, auto accidents, or even SIDS.[21][22]

Forced circumcision

United States Military

American soldiers serving in World War II were subjected to regular inspections of their genitals. If uncircumcised, the soldiers risked being ordered to undergo immediate circumcision.[23]

Non-therapeutic circumcision of male children

Human babies, because they are not yet in possession of language, are incapable of giving or refusing consent for being circumcised. The element of force has led some scholars to view the circumcision of baby boys as a category of forced circumcision.[24] There are, however, physicians in the United States who argue strongly for routine circumcision of newborn babies; and circumcision is widely accepted as a postnatal procedure in American hospitals.[25] Parental consent is required.[26] A statement published by the American Academy of Pediatrics in 1999 declares that "parents should determine what is in the best interest of the child... It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in additions to the medical factors, when making a decision."[27] In the United Kingdom, where routine circumcision has now become far less prevalent than in the United States, a written consent of both parents is required, if a physician is to perform a non-therapeutic circumcision of a child.[28]


In recent years, legal writers in several English-speaking countries have been questioning the practice of acceding to parental wishes.[29] For example, critics have pointed out that, in the United States, more than 1.3% of male neonatal deaths are attributable to the complications of non-therapeutic circumcision surgery.[30][31]


References

  1. Taylor, J.R.; A.P. Lockwood and A.J. Taylor (1996-2). "The prepuce: Specialized mucosa of the penis and its loss to circumcision". British Journal of Urology International 77: 291-95. PMID 8800902. http://www.cirp.org/library/anatomy/taylor/. 
  2. Template:Cold and Wiswell (1995) | see more</p>
  3. Cold, Christopher; McGrath, Kenneth (1999). "Anatomy and histology of the penile and clitoral prepuce in primates". Male and female circumcision: medical, legal, and ethical considerations in pediatric practice. New York. ISBN 0306461315. http://www.cirp.org/library/anatomy/cold-mcgrath/. 
  4. American Academy of Pediatrics: Circumcision Policy Statement; Task Force on Circumcision" Pediatrics Vol 103 No.3 March 1999, pp.686-693. (Statement Reaffirmed Sept. 1, 2005)."
  5. "Circumcision: Position Paper on Neonatal Circumcision. Board Approved: August 2007 Reaffirmed". Official American Academy of Family Physicians Website. http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html. Accessed 5/2/2011.
  6. "Report 10 of the Council on Scientific Affairs (I-99): Neonatal Circumcision". American Medical Association Official Website. http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml. Accessed May 4, 2011.
  7. Where We Stand: Circumcision". AAP Official Website. 03/23/2011. http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx
  8. "Parents' Guide to Circumcision". http://www.pollockclinics.com/circumcision/circumcision-guide.html. Retrieved 2011-04-08. "To calm the baby during the procedure, a sugar filled gauze pacifier soaked with sweet juice is used, and soothing music is played in the room." 
  9. "Before the Circumcision". 2011-04-08. http://www.pollockclinics.com/circumcision/circumcision-before.html. Retrieved 2011-04-08. "During the circumcision, your son will receive sugar pacifiers to suck on which reduce his pain perceptions." 
  10. "Before the Circumcision". 2011-04-08. http://www.pollockclinics.com/circumcision/circumcision-before.html. Retrieved 2011-04-08. "Then in our office, he will have topical anesthetic applied to his penis." 
  11. "Parents' Guide to Circumcision". http://www.pollockclinics.com/circumcision/circumcision-guide.html. Retrieved 2011-04-08. "We use extensive pain control methods including Tylenol, a sugar solution (to reduce pain perceptions), a topical freezing cream, and a local anesthetic injection." 
  12. Taeusch, H William; Alma M Martinez, J Colin Partridge, Susan Sniderman, Jennifer Armstrong-Wells, Elena Fuentes-Afflick (April/May 2002). "Pain During Mogen or PlastiBell Circumcision". Journal of Perinatology 22 (3): 214-218. http://www.nature.com/jp/journal/v22/n3/full/7210653a.html. Retrieved 2011-04-08. "...more than half of the study group had what we considered excessive pain/discomfort over the course of the entire procedure.". 
  13. Williamson, Paul S.; Nolan Donovan Evans (August 1986). "Neonatal Cortisol Response to Circumcision with Anesthesia". Clinical Pediatrics 25 (8): 412-416. http://cpj.sagepub.com/content/25/8/412.abstract. Retrieved 2011-04-08. "The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine.". 
  14. "Before the Circumcision". 2011-04-08. http://www.pollockclinics.com/circumcision/circumcision-before.html. Retrieved 2011-04-08. "During the circumcision, your son will receive sugar pacifiers to suck on which reduce his pain perceptions." 
  15. Slater, Rebeccah; Laura Cornelissen, Lorenzo Fabrizi, Debbie Patten, Jan Yoxen, Alan Worley, Stewart Boyd, Judith Meek, Prof Maria Fitzgerald (2010-10-09). "Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial". Lancet, The 376 (9748): 1225-1232. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961303-7/fulltext. Retrieved 2011-04-08. "Our data suggest that oral sucrose does not significantly affect activity in neonatal brain or spinal cord nociceptive circuits, and therefore might not be an effective analgesic drug. The ability of sucrose to reduce clinical observational scores after noxious events in newborn infants should not be interpreted as pain relief.". 
  16. Taddio, Anna; Morton Goldbach, Moshe Ipp, Bonnie Stevens, Gideon Koren (1995). "Effect of neonatal circumcision on pain responses during vaccination in boys". The Lancet 345 (8945): 291-2. PMID 7837863. http://www.cirp.org/library/pain/taddio/. 
  17. Taddio, Anna; Katz J, Ilersich AL, Koren G. (March 1997). "Effects of neonatal circumcision on pain response during subsequent routine vaccination". The Lancet 349 (9052): 599 - 603. PMID 9057731 doi: 10.1016/S0140-6736(96)10316-0. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)10316-0/fulltext. 
  18. Boyle, Gregory J.; Gillian A. Bensley (July 2001). "Adverse Sexual and Psychological Effects of Male Infant Circumcision". Psychological reports 88 (3, Part 2): 1105–1106. doi:10.1046/j.1464-410x.1999.0830s1085.x. PMID 11597060. http://www.cirp.org/library/psych/boyle5/. 
  19. Van Howe, RS; Cold CJ (1997-04-02). "Advantages and Disadvantages of Neonatal Circumcision". The Journal of the American Medical Association 277 (13): 1052-7. PMID 9218663. http://www.ncbi.nlm.nih.gov/pubmed/9218663. 
  20. Cold, C.J.; J.R. Taylor (1999-1). "The prepuce". British Journal of Urology International 83: 34-44. PMID 10349413. http://www.cirp.org/library/anatomy/cold-taylor/. 
  21. Bollinger, Dan; Boy's Health Advisory (2010-4-26). "Lost Boys: An Estimate of U.S. Circumcision-Related Infant Deaths". Thymos: Journal of Boyhood Studies 4 (1): 78-90. doi:10.3149/thy.0401.78. http://www.mensstudies.com/content/b64n267w47m333x0/?p=7ebbd6b446d940cbbd4274c095754b12π=5. 
  22. ICGI (2010-4-26). "Infant circumcision causes 100 deaths each year in US". International Coalition for Genital Integrity. http://www.icgi.org/2010/04/infant-circumcision-causes-100-deaths-each-year-in-us. 
  23. Schoen, Ed (2005). Dianne Yeakey. ed. On Circumcision. Georgetown, Canada: RDR Books. pp. 72-73. ISBN 1-157143-123-3. http://tinyurl.com/schoenoncircumcision. "For a critical view, see Sorrells, "The History of Circumcision," p. 333" 
  24. For example, Frederick M. Hodges, a medical historian, writes: "In the late 1970s, as the Americans were growing increasingly aware of the abuses of power rampant throughout the nation's social institutions, influential grass-roots movements protesting the forced circumcision of American children sprang up nationwide." F. Hodges, "A Short History," p. 31; see also Glick, Marked in Your Flesh, pp. 273-281.
  25. Fletcher, Christopher R. (1999). "Section 5". Circumcision in America in 1998: Attitudes, Beliefs, and Charges of American Physicians. New York: Kluwer Academic/Plenum Publishers. pp. 259-271. 10.1007/978-0-585-39937-9_19. http://www.springerlink.com/content/h2150v731233m177/. 
  26. See, e.g., Shephard and Shephard, The Complete Guide, p. 125.
  27. Lannon and Bailey, "Circumcision Policy Statement," p. 691.
  28. Re J (child's religious upbringing and circumcision), Family Court Reports, vol. 1 (2000), pp. 307-314.
  29. See, e.g., Somerville, "Therapeutic and Non-Therapeutic Medical Procedures"; Poulter, English Criminal Law; Chessler, "Justifying the Unjustifiable"; Smith, "Male Circumcision."
  30. Bollinger, Dan; Boy's Health Advisory (2010-4-26). "Lost Boys: An Estimate of U.S. Circumcision-Related Infant Deaths". Thymos: Journal of Boyhood Studies 4 (1): 78-90. doi:10.3149/thy.0401.78. http://www.mensstudies.com/content/b64n267w47m333x0/?p=7ebbd6b446d940cbbd4274c095754b12π=5. 
  31. ICGI (2010-4-26). "Infant circumcision causes 100 deaths each year in US". International Coalition for Genital Integrity. http://www.icgi.org/2010/04/infant-circumcision-causes-100-deaths-each-year-in-us. 
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